Session 7:
Up and Down the Tract: Practical Approaches
to Common GI Complaints
Learning Objectives
1. Consider the effectiveness of various PPI dosing regimens, and the risk/benefit
profile of long-term GERD therapy.
2. Understand the benefit/risk scale for long-term treatment of GERD.
3. Explore the etiologies of fecal incontinence and proven treatment
modalities.
Session 7
Up and Down the Tract: Practical Approaches to Common GI Complaints
Faculty
John M. Inadomi, MD
Cyrus E. Rubin Endowed Chair in Medicine
Professor of Medicine and Head,
Division of Gastroenterology
University of Washington School of Medicine
Seattle, Washington
Dr John Inadomi, the Cyrus E. Rubin endowed chair in medicine, is currently a professor of medicine and head of the division
of gastroenterology in the department of medicine at the University of Washington School of Medicine, Seattle. He received
an undergraduate degree in biomechanical engineering from Massachusetts Institute of Technology, Massacusetts, and his
medical degree from the University of California, San Francisco (UCSF). He has been on the faculty of the University of New
Mexico, the University of Michigan, and UCSF where he was the Dean M. Craig endowed chair in gastrointestinal medicine.
Dr Inadomi is a gastroenterologist with expertise in comparative effectiveness research. He has received funding from the
National Institutes of Health (NIH) to evaluate new techniques to decrease mortality from esophageal adenocarcinoma and to
test novel interventions to increase adherence to colorectal cancer screening tests. He is currently the chair of the American
Gastroenterological Association clinical practice and quality management committee, senior associate editor of the American
Journal of Gastroenterology, a member of the American Board of Internal Medicine subspecialty board in gastroenterology, and
a standing member of the NIH Health Services: organization and delivery study section.
Peter S. Buch, MD, FACP
Associate Professor
University of Connecticut School of Medicine
Assistant Professor
University of New England College of Osteopathic Medicine
Manchester, Connecticut
While adrift in medical school, I had the opportunity of meeting Dr Terrance McNally and Dr Sam Iyer at Downstate, who
helped me reach an epiphany. Yes, medicine was challenging, but it could also be enjoyable. And yes, I COULD do it! With
this direction, I did my internship, residency and eventually fellowship at Long Island Jewish Hospital. There, I met some
additional outstanding gastroenterologists, Drs Katz, Katzka, and Bank, who were my role models of knowledge,
understanding and compassion.
Since 1981, I have been practicing in Eastern Connecticut, fulfilling the pathway so ably set by my mentors. I have been
actively teaching at the University of Connecticut School of Medicine and UNECOM. I am proud to have been involved in
policy formation in Connecticut and have devoted my time to numerous hospital and national committees.
Teaching is my PASSION and I hope to share that passion with you.
Faculty Financial Disclosure Statements
The presenting faculty reports the following:
Dr Inadomi is a consultant for Cernostics and Given Imaging; and serves as a member of advisory committees or review panels
for Roche Diagnostics.
Dr Buch receives speaking/teaching honoraria from Abbvie, Ironwood/Forest Pharmaceuticals, and Prometheus Labs.
Presenter Disclosure Information
SESSION 7
The following relationships exist related to this presentation:
7:45–9:15am
►Dr Inadomi is consultant for Given Imaging and Cernostics,
and is a member of advisory committees/review panels for
Roche Diagnostics.
►Dr Buch receives speaking/teaching honoraria from Abbvie,
Ironwood/Forest Pharmaceuticals, and Prometheus Labs.
Up and Down the Tract: Practical
Approaches to Common GI Complaints
SPEAKERS
John Inadomi, MD
Peter S. Buch, MD, FACP
Off-Label/Investigational Discussion
►In accordance with pmiCME policy, faculty have been asked to
disclose discussion of unlabeled or unapproved use(s) of
drugs or devices during the course of their presentations.
Learning Objectives
Case Presentation 1
47-year-old man with worsening heartburn
• Reports almost daily post-prandial symptoms in spite of
daily omeprazole
• Nocturnal heartburn can awaken him from sleep
• Denies weight loss, anorexia, nausea or vomiting,
difficulty swallowing or painful swallowing
• Has gained 20 pounds over the past year but otherwise
his health is unchanged
• Eats dinner at 6:30 pm, drinks beverages up until 10:00
pm before retiring to bed at 10:30 pm
• Props his head up on 2 or 3 pillows to avoid reflux
• Consider the effectiveness of various PPI dosing regimens, and
the risk/benefit profile of long-term GERD therapy
• Determine the distinctions between gluten sensitivity and
celiac disease and whether they impact management
decisions
• Explore the etiologies of fecal incontinence and proven
treatment modalities
GERD: Definitions
Case Presentation 1 (cont.)
Lab work 4 months ago:
Normal CBC and CMP
Physical exam:
White male
Normal vital signs
BMI 31.2 kg/m2
Gastroesophageal Reflux Disease (GERD)
“symptoms or complications resulting from the reflux of
gastric contents into the esophagus, oral cavity (including
larynx) or lung
Reason for
appointment:
He heard that heartburn
can lead to cancer
He also wants to know if
there are any more
effective treatments
Syndromes with injury
• Esophagitis
• Stricture
• Typical reflux syndrome
• Barrett's esophagus
• Reflux chest pain
syndrome
• Adenocarcinoma
Vakil et al, Am J Gastroenterol 2006;101:1900
Katz et al. Am J Gastroenterol 2013;108:308–328
CBC=complete blood count; CMP=complete metabolic panel; BMI=body mass index
1
Symptomatic
Syndromes
Time Trends of GERD Symptoms: Review of
Cross-Sectional Population- Based Studies
Endoscopy Negative Disease
A heterogenous group of disorders presenting as typical GERD
symptoms in the absence of visible esophageal injury at
endoscopy
35
30
Non-Erosive Reflux Disease
(NERD)
“The presence of typical GERD
symptoms due to intraesophageal
acid
exposure in the absence of visible
esophageal injury at endoscopy”.
Functional Heartburn (Rome III)
25
• Burning retrosternal pain or
discomfort
Prevalence of at least weekly heartburn
and/or acid regurgitation
Europe
USA
ASIA
South America
20
15
• Absence of evidence that GERD is
the cause of symptoms
10
• Absence of histopathology-based
esophageal motility disorders
5
0
1980
1985
1990
1995
2000
2005
2010
Date of publication
 All that is endoscopy negative is not NERD
EL-Serag HB. Clin Gastroenterol Hepatol. 2007;5:17-26.
Factors Responsible for the Changing
Epidemiology of GERD
Higher Body Mass Index Increases Risk of
GERD Symptoms
• Even moderate weight gain among persons of normal weight
can cause or worsen reflux symptoms
• Weight loss is associated with a decreased risk of symptoms
• Aging population1
• Increasing prevalence of obesity2
Study of 2306 women with at least weekly GERD
symptoms and 3904 with no symptoms
• Use of drugs that affect LES pressure and gastric emptying3
Odds ratio
• Self-treatment / access to OTC medications?
• Dietary habits, other lifestyle factors?
P < .001 for trend
LES=lower esophageal sphincter
Body mass index (kg/m2)
1. Lee et al. Clin Gastroenterol Hepatol. 2007;5:1392-1398.
2. Watanabe et al. J Gastroenterol. 2007;42:267-274.
3. Bonatti et al. J Gastrointest Surg. 2007. Jul;11(7):923-8.
Jacobson BC, et al. N Engl J Med. 2006;354:2340-2348.
Diagnostic Testing for GERD
Diagnostic Testing for GERD cont’d
Diagnosis is based on typical symptoms of heartburn and regurgitation
Additional testing often not needed
• pH monitoring
• Useful for refractory symptoms and chest pain
• Endoscopy and biopsy:
Indications:
• Multichannel intraluminal impedance
- Alarm features such as dysphagia, odynophagia, vomiting,
weight loss, and anemia
- For screening patients at high risk of complications of GERD
• Esophageal manometry
• Helpful for diagnosis of non-acidic reflux
• Useful in evaluation of dysphagia and chest of
suspected esophageal origin
• Barium swallow/upper gastrointestinal series
– Useful to detect anatomic abnormalities (e.g., hiatal hernia,
stricture)
– Does NOT play a role in GERD diagnosis
Rosen R, et al. Am J Gastroenterol. 2004;99:2452-2458
Stavroulaki P. Int J Pediatr Otorhinolaryngol. 2006;70:579-590
Rudolph CD, et al. J Pediatr Gastroenterol Nutr. 2001;32(suppl 2):S1-S31
Katz P, et al. Am J Gastroenterol 2013;108:308–328
2
Upper Endoscopy for GERD: Advice from the
American College of Physicians
Indicated in men & women with heartburn and:
• Alarm Features
– Dysphagia, bleeding, anemia, weight loss, vomiting
• Persistent symptoms despite PPI BID for 4-8 weeks
• Severe erosive esophagitis after a 2-month course of PPI
therapy (to assess healing & rule out Barrett’s esophagus)
• History of esophageal stricture with recurrent dysphagia
Other indications:
• Men >50 years with >5 years of GERD symptoms and other
risk factors, including:
– nocturnal GERD, hiatal hernia, obesity, tobacco, intraabdominal fat
• Surveillance of Barrett’s esophagus
PPI= proton pump
Shaheen N, et al. Ann Int Med. 2012:157:808-16.
Management of GERD in 2013
inhibitor
PPIs vs H2RAs vs Placebo for Erosive
Esophagitis (EE)
Impact of Lifestyle Changes on GERD:
What is the Evidence?
16 trials examined effectiveness of lifestyle changes
PPIs
H2RA
Placebo
100
80
% 60
Total
Healed
40
20
0
0
2
4
6
8
12
Time, wks
LES = lower esophageal pressure
Chiba et al. Gastroenterology. 1997;112:1798-1810.
Khan et al. Cochrane Database Syst Rev. 2007;(2):CD003244.
Kaltenbach T, et al. Arch Intern Med. 2006;166:965-971.
Systematic Review of Symptom Response
With PPI in Erosive and Nonerosive GERD
PPI=proton pump inhibitor; H2RA = h2
receptor antagonist
On-Demand vs. Continuous PPI Therapy for
GERD
176 pts with NERD or Grade I/II esophagitis and
frequent relapses treated with rabeprazole 10 mg
NERD (n=1854)
*** p<0.001 NERD vs EE
P = 0.065
EE = erosive esophagitis; NERD = non-erosive reflux disease
Dean et al, Clin Gastroenterol Hepatol 2004;;2(8):656-64
Bour et al. Aliment Pharm Ther 2005;21:805
3
Traditional PPI Therapy:
Is there Room for Improvement?
PPI Therapy: When is more better?
Mail survey of 617 GERD patients from a community- based
physician network in Massachusetts1
• Recent studies suggest that twice daily PPI controls
intraesophageal acid exposure no better than once daily PPI
in patients with GERD
– 77% PPI qd & 23% PPI bid
– 80% of qd users took their PPI in the AM
• Daily PPI therapy controls intraesophageal acid exposure
better than every other day PPI
– 59% took their PPI before a meal
• Sustained symptom response with daily PPI therapy is
inversely related to BMI
– >40% supplemented their PPI with OTC medications
– 27% were “neither satisfied nor dissatisfied”,
“dissatisfied”, or “very dissatisfied” with PPI therapy
• In obese patients with erosive esophagitis, twice daily PPI
may provide better symptom relief than once daily PPI
Recent systematic review found that satisfaction was associated
with symptom improvement and improved quality of life2
Chey WD, et al. Current Med Res and Opin. 2009;25:1869-1878
Van Zanten SJ et al. Can J Gastroenterol. 2012 Apr;26(4):196-204
Gawron AJ, et al. Clin Gastroenterol Hepatol 2012;10:620-5. Bour et al. Aliment Pharm Ther 2005;21:805
LARS vs. Esomeprazole for Chronic GERD: 3 Year
Analysis from the LOTUS Trial
Potential Safety Risks of PPIs
• Open, parallel group study in 11
European sites
• 412 patients with chronic GERD (EE
& response to PPI) randomized to
LARS or esomeprazole 20 mg/day
• PPI dose escalation allowed
• Primary outcome: % of pts
remaining in remission at 3 years
• 23% required increased PPI dose
over time
• No between-group differences in
improvement of microscopic
esophagitis
Safety Issue
Clinical Significance
Cytochrome P450 interaction
Negligible
Clopidogrel interaction
Avoid use with omeprazole
Clostridium difficile infection
Probable
Other enteric infections
Probable
Rebound hypersecretion
Negligible
Fractures
Unclear
Idiosyncratic reactions (AIN, hepatitis)
Rare
Anaphylaxis
Rare
Pregnancy
Likely negligible
Hypomagnesemia
Rare (seen with > 1 year
treatment)
LARS = laparoscopic antireflux surgery
Lundell, et al. Gut. 2008;57:1207
Fiocca, et al. Am J Gastroenterol 2010;105:1015
Adapted from Parikh NY, Howden CW. GI Clin NA, 2010;39:529
Risk of Fractures with PPI Use:
Conflicting Evidence
Warnings Added to PPI Labels in 2012
Safety Issue
Clinical Significance
Interaction with clopidogrel
Concomitant use of clopidogrel
with 40 mg esomeprazole reduces
pharmacologic activity of
clopidogrel. Avoid concomitant use
of omeprazole or esomeprazole
with clopidogrel.
Clostridium difficile associated
diarrhea
Concomitant use with
methotrexate (primarily at high
dose)
2 Analyses from the 10-Year Canadian Multicenter
Osteoporosis Study
Study Design Prospective cohort
study
Population
9,423 participants
followed for 10 years
Results
PPI associated with
significantly shorter
time to first
nontraumatic fracture,
even after controlling
for multiple fracture
risk factors
Should be considered for diarrhea
that does not improve.
PPI use may elevate and prolong
serum levels of methotrexate
and/or its metabolite, possibly
leading to methotrexate toxicities.
Temporary withdrawal of PPI may
be considered.
http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020973s029lbl.pdf
http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/020406s078-021428s025lbl.pdf
Fraser LA, et al. Osteoporos Int. 2013 Apr;24(4):1161-8.
Targownik LE, et al. Am J Gastroenterol. 2012 Sep;107(9):1361-9.
4
Study Design
Prospective cohort study
Population
8,340 patients with BMD
at baseline
4,512 patients with BMD
at 10 years
Results
PPI significantly
associated with lower
baseline BMD (femoral
neck and total hip)
but not with significant
acceleration in BMD loss
at 5 and 10 years
BMD = bone mineral density test
Heartburn: More Than One Disease
Management of GERD: Summary
• Prevalence of GERD and its complications are increasing
• PPIs are the most effective medical therapy
• Minimum effective dosing should be utilized
• BID dosing is common but offers little incremental benefit
over QD dosing
• Histamine receptor antagonists are effective for occasional
heartburn
• Surgery in expert hands provides another highly effective
treatment option for GERD
• Novel procedures and devices deserve further study
• A variety of emerging therapies are in development for
patients with GERD symptoms
• Pathological acid reflux
• Non-acid reflux
• Disturbed motility
• Visceral hypersensitivity/brain-gut interactions
– Chemical, osmolar, mechanical
• Psychological abnormalities
– Somatoform disorder
Case Presentation 2
• 28-year-old woman
• Reports abdominal bloating and discomfort, increased loose
stools ranging from 2 to 3 a day without blood
Celiac Disease and Other Conditions
• Also complains of fatigue and headaches
• On the advice of a friend, started a gluten-free diet two
months ago
Update on Intolerance or Sensitivity to
Wheat or Gluten
• Feels better but wants to know if she has celiac disease and
if she should stay on her diet, which she finds expensive and
difficult to adhere to
Celiac Disease Changes to Intestinal Mucosa
What is Gluten Sensitivity?
Oslo Definitions
A chronic small intestinal
Gluten Sensitivity Due to
immune-mediated enteropathy
Celiac Disease (CD)
precipitated by exposure to
dietary gluten in genetically
predisposed individuals
Non-Celiac Gluten
Sensitivity (NCGS)
• Inflammatory reaction targets mucosa of small intestine,
leading to crypt hyperplasia and villous atrophy
• Net results are impaired nutrient absorption and increased
water and solute secretion
One or more immunological,
morphological and/or
symptomatic alterations
triggered by gluten ingestion in
individuals in whom celiac
disease has been excluded
Presuttii JR et al. Am Fam Physician. 2007;76:1795-1802. AGA Institute, Gastroenterology. 2006;131:1977–1980.
Ludvigsson JF, et al. Gut. 2013 Jan;62(1):43-52
5
Proposed Mechanisms of Non-Celiac Wheat
Sensitivity
Good and Bad (for CD) Grains – Increasing
Consumption of Wheat Worldwide
Wheat ingestion
Poorly Absorbed
Carbohydrates
Bad
Gluten-mediated
Rye
Triticale
Kamut
Couscous
Nocebo
Effect
Excess Fructans
Fermentation
Gas production &
SCFA formation
Microbiome
changes
Immune Activation/
Altered
Low grade
Permeability
inflammation
GI Symptoms
Good
Oats
Potato
Soybean
Sorghum
Wheat
Barley
Spelt
Bulgur
Rice
Corn
Tapioca
Arrowroot
Buckwheat
SCFA = short chain fatty acids
Adapted from Eswaran S, et al. Gastroenterol Hepatol 2013;9:85.
Vazquez-Roque MI, et al. Gastroenterology 2013;144:903
Changing Picture of Celiac Disease
The Celiac Iceberg
• Classical form less prevalent now
• Average age of diagnosis in 5th decade
“Atypical is typical:” 50% of newly diagnosed celiac
patients present with atypical symptoms
• Many patients are overweight
• Seroprevalence Male=Female; Diagnosis M<F
• Other presentations are being increasingly recognized:
– Obstetrical problems
– Neuropsychiatric manifestations
– Related autoimmune conditions
– Many others – true associations or chance?
Symptoms and Conditions That Should Prompt
Consideration of Celiac Disease
Common Symptoms in Celiac Disease
• Altered bowel habits
– Diarrhea, constipation and mixed pattern
• Fatigue
• Borborygmi, flatulence
• Abdominal discomfort or pain
• Weight loss
– However patients with CD can be overweight and even obese
• Abdominal distention or bloating
• Note that there are many other presentations of celiac disease
including an asymptomatic state
GI
symptoms
Other
inflammatory
luminal GI
disorders
First and
second
degree
relatives
Celiac
Disease
Miscellaneous
conditions
Crowe, SE, In The Clinic : Celiac Disease, Ann Int Med, 154:ITC5-14, 2011
6
Autoimmune
endocrine
disorders
Hepatobiliary
conditions
Extraintestinal
presentations
Niewinski MM. J Am Diet Assoc. 2008;108:661-672.
Presuttii JR et al. Am Fam Physician. 2007;76:1795-1802.
Green PHR JAMA. 2009;302(11):1225-1226.
Crowe, SE, In The Clinic : Celiac Disease, Ann Int Med, 154:ITC5-14, 2011
Autoimmune
connective
tissue
disorders
Celiac Disease:
Asymptomatic and Potential Forms
What are the Best Serologic Tests for
Screening for CD?
These forms are often found in first- or second-degree relatives
of patients with biopsy proven celiac disease or in those with
CD-associated diseases (DH, autoimmune conditions) and all
have HLA DQ susceptibility genes
• Depends on prevalence and age of population
• Overall, TTG IgA is the recommended test to screen for
disease but sensitivity varies with lower levels (≤90% )
reported in routine practice
• 1 in 10 false negative rate for TTG IgA (not all attributable to
IgA deficiency)
• TTG, EMA less sensitive for milder histologic stages
• Antibodies to GDP are less sensitive than to TTG*
• Intestinal biopsies remain the gold standard
• Asymptomatic, Subclinical or Silent CD
– No or imperceptible symptoms
• Potential or Latent CD
– Have positive serology but negative small bowel biopsies
who are at increased risk of developing CD
• Genetically at risk of CD
– Family members of patients with CD
TTG IgA = tissue transglutaminase antibody; EMA = anti-endomysial antibodies;
GDP = gluten deamidated peptide
HLA DQ = DQ locus of the human leukocyte antigen; DH = dermatitis herpetiformis
AGA Technical Review, Gastroenterology, 131:1981, 2006.* Lewis, NR, Aliment Pharmacol Ther, 31: 73, 2010
Ludvigsson JF et al. Gut. 2013 Jan;62(1):43-52
Patients Already on a Gluten-Free Diet:
How to Test for Celiac Disease?
When to Use Genetic Testing
• How to test:
– PCR of RNA blood sample
• Who to test:
– Patients on a gluten-free diet who are candidates to
undergo a gluten challenge to confirm possible CD
– Equivocal histology and serology findings in which a
negative test result would make CD highly unlikely
• How often to test: Once in a lifetime
• Depends of duration and stringency of GFD
– If truly on a GFD for years, it is difficult to prove CD
– Most patients on a self-taught GFD are not highly gluten-free
• Serology can take over a year to normalize
• Histology can take years to become normal
• Thus, if an undiagnosed patient wants an assessment for possible
CD recommend assessing with serological tests, HLA DQ2/8 and
EGD with biopsies within the first year on a GFD
• Absence of HLA DQ2.2, 2.5 or 8 effectively excludes CD now or in the
future
EGD = esophagogastroduodenoscopy
Sugal, E, et al. Digestive & Liver Disease, 42:352, 2010
Crowe, SE. In The Clinic : Celiac Disease, Ann Int Med,2011 154:ITC5-14,
Crowe, SE. In The Clinic : Celiac Disease, Ann Int Med,2011 154:ITC5-14,
Non-Celiac Gluten Sensitivity (NCGS) or
Wheat Intolerance?
Between Celiac Disease & IBS:
The “No Man’s Land” of Gluten Sensitivity
• Not a new entity, reported in 1980
• Prevalence unknown, probably greater than celiac disease,
but no data
• Varies from 0.548% (NHANES) to 30% of US!!
• Studies reporting prevalence reflect referral bias
• Currently no specific criteria or validated tests for diagnosing
NCGS!!
• Cannot differentiate between intolerance of gluten, wheat
starch or other causes of wheat intolerance/sensitivity
• Reported in association with allergic diseases
NHANES = National Health and Nutritional Examination Survey
Cooper, BT, et al. Gastroenterol, 79; 801, 1980
Massari, S, et al, Ine Arch Allergy Immunol, 155;389, 2011
Sabatino, AD & Corazzo, GR, Ann Intern Med, 156, 309: 2012
7
Gluten Causes Symptoms in IBS Patients
Without Celiac Disease
Possible Mechanisms of Wheat
Intolerance in IBS and other FGID
Innate immune
reaction to
gluten
Nocebo effect
Low grade
inflammation
Non-Celiac
Celiac
Wheat
Intolerance
IgE mediated
wheat allergy
Starch/CHO
Malabsorption
Altered
Permeability
FGID = functional gastrointestinal disorders
Sabatino & Corazza, Ann Int Med 2012;156:309-1
Vazquez-Roque MI, et al. Gastroenterology 2013;144:903 1
VAS = Visual Analogue Scale
Summary of CD, NCGS and Other
Intolerances to Wheat
• Celiac disease is not rare (1 in 100-300)
Management Strategies for
Fecal Incontinence
• CD can coexist with or mimic IBS and other FGID
• Increased reporting of NCGS
• True prevalence of NCGS is unknown
• Cannot clinically differentiate NCGS and CD
• Gluten-free diet remains the mainstay of therapy for both
conditions
• How GS contributes to functional GI disorders remains unclear
but multiple mechanisms implicated
• Other forms of wheat intolerance are emerging
• Additional research is needed! Stay tuned….
FGID = Functional GI Diseases
NCGS = Non Celiac Gluten Sensitivity
Fecal Incontinence (FI): Epidemiology and
Burden of Illness
Case Presentation 3
Prevalence:
7-25% in women
33-65% in nursing home residents
36.2% outpatients self-reported FI but only
2.7% had the diagnosis
• 72-year-old woman comes to see you for “diarrhea”
• Reports “accidents” several times in the past few months
• Incontinence episodes tend to occur when her stool are soft
or loose in consistency
• No longer goes out socially and cannot travel
• History of lumbar laminectomy in her 50s and 3 vaginal
deliveries in her 20s, the first with prolonged labor and need
for forceps
• No new medications, denies laxatives
• No weight loss, rectal bleeding, rectal pain
• Her last colonoscopy at age 70 was normal apart from
scattered left-sided diverticulosis
Significant economic burden and negative
effect on quality of life:
Adult diapers: >$400 million per year
Greater number of outpatient & GI visits
with a 55 % increase in direct costs for FI
patients
Melville JL, et al. Am J Obstet Gynecol 2005;193:2071–2076
Dunivan Gc et al. Am J Obstet Gynecol 2010;202:493.e1-6
Nygaard I, et al. JAMA 2008;300:1311–1316
Menees S et al. Dis Col Rectum 2013;56:97-102
Shah BJ, et al. Am J Gastroenterol 2012;107:1635-42
Bharucha A, et al. Am J Gastroenterol 2012;107:902-11
8
Risk Factors:
• Increasing age
• Poor physical or mental
health
• Anorectal procedures
• Diarrhea
• Constipation (in the
elderly)
• Episiotomy
• Increased parity
• Diabetes
• Urinary incontinence
• Fecal urgency
• Tobacco abuse
Types of Fecal Incontinence
Fecal Incontinence Associations
Passive
incontinence1,2
Urge
incontinence1,2
Fecal
Seepage1,2
• Unaware of stool
or gas passage;
• Passage of feces
despite
awareness &
attempted
retention
• Leakage of small
amounts of fecal
material
• Usually
attributable to a
weak/ damaged
IAS
• Majority
associated with
weak/ damaged
EAS
Passive
Incontinence
• aging
• anorectal
surgery
• diarrheal
illnesses
• obstetric injury
• Often due to
impaired rectal
sensation or
incomplete
closure of the
anal cushions
IAS = internal anal sphincter; EAS = external anal sphincter
Diagnostic Evaluation
• Limited
evidence of
benefit
• MRI: Evaluates global pelvic floor anatomy, sphincter
morphology, motion
Rao SSC. Clin Gastroenterol Hepatol. 2010;8:910-919.
Conservative Management of Fecal
Incontinence
Surgical
Therapies
More invasive
• Pain
• Infection
CVA
dementia
diabetes
hemorrhoids
pelvic nerve or
spinal cord
injury
• Endoanal U/S: Assess IAS and EAS thickness, integrity
Treatment Options for Fecal Incontinence
• Generally safe
•
•
•
•
•
• Anorectal manometry: Quantifies sphincter pressures,
sensation, rectal compliance and recto-anal reflexes
Rao SS et al. Am J Gastroenterol. 2004;99:1585-1604.. Rao SS et al. Gastroenterology 2004;126:S14-S22.
Less invasive
proctitis
diarrheal illnesses
obstetric injury
neurological
diseases
(Parkinson's, MS)
Diagnostic Tests Offered by Specialists
• History:
• Demographics
• Duration, nature, frequency, bowel habits, impact on quality of
life, obstetric history, other medical conditions, urinary
incontinence
• Physical exam
• Digital rectal exam
• Diagnostic examinations
• Anorectal manometry
• Anal endosonography
• Anal or pelvic MRI (static or dynamic)
• Defecography
Dextranomer
Microsphere
Injection
•
•
•
•
Fecal
Seepage
1. Nelson RL. Gut. 2004;126:S3-S7.
2. Rao SS et al. Am J Gastroenterol. 2004;99:1585-1604.
3. Rao SS et al. Gastroenterology 2004;126:S14-S22.
1. Rao SS et al. Am J Gastroenterol. 2004;99:1585-1604.
2. Rao SS et al. Gastroenterology 2004;126:S14-S22.
Conservative
Therapies
Urge
Incontinence
• Potential safety
issues
• Marginal long
term benefits
Whitehead WE, Bharucha AE. Gastroenterology. 2010;138:1231-1235.
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Pharmacologic Treatments for Diarrhea
Biofeedback for Fecal Incontinence
 Drugs are not specifically approved for fecal incontinence
•
Biofeedback
Antidiarrheal agents
– Loperamide, Diphenoxylate
•
A process in which a person
learns to reliably influence
body responses through the
use of feedback cues,
ultimately leading to the
correction of maladaptive
behaviors.
Bile salt resins
– Cholestyramine
•
Anticholinergics
– Hyoscyamine, Dicyclomine
•
Tricyclic agents
– Amitriptyline, Nortriptyline, Desipramine
•
Types of Biofeedback
• Pressure (perineometry)
• Electromyography (EMG)
• Sensory (rectal balloon
retraining)
• Pelvic floor muscle
contraction indicator
devices
• Real time ultrasound
Alosetron ONLY for severe IBS-D in women
Rao SS et al. Am J Gastroenterol. 2004;99:1585-1604.
Dextranomer Microspheres Injection
Biofeedback for Fecal Incontinence
Response defined as a reduction in # episodes by ≥ 50%
Significantly higher responder rates in injection group at 6 months
Correcting Abnormal
Rectal Sensation
80
60
Proportion
responders50
(%)
40
at 6 mos
Physical
Therapy and
Biofeedback
Training
Sphincter &
Pelvic Floor
Strengthening
P=.004
53.2%
n=136
30.7%
n=70
20
Improving
Coordination
0
Injection
Palsson OS, Heymen S, Whitehead WE. Applied Psychophysiol Biofeedback. 2004;29:153-174
Sham
Graf W et al. Lancet. 2011; 377: 997–1003.
Surgical Management of Fecal Incontinence
Fecal Incontinence Summary
•
•
•
•
•
•
Fecal Incontinence is NOT rare
FI is not the same as diarrhea
FI dramatically reduces QOL
Important to recognize the risk factors for FI
History & physical examination are key in diagnosis
Refer to a specialist when considering specialized testing
such as manometry or anal ultrasound
• Conservative approaches include bulking stool, antidiarrheals and biofeedback
• Dextranomer injection, sacral nerve stimulation and surgery
are additional treatments that can help selected FI patients
Whitehead WE, Bharucha AE. Gastroenterology. 2010;138:1231-1235.
Glasgow SC, Lowry A. Dis Colon Rectum 2012;55:482-490
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